Quality assurance -Models & approaches

Introduction
Hospitals in India have a high burden of infections in
their intensive care units (ICU) and general wards,
many of which are resistant to antibiotic treatment.
A report by Global Antibiotic Resistance Partnership
(GARP) .
Antibiotic resistant infections are difficult, and
sometimes impossible, to treat. They lead to longer
hospital stays, increased treatment costs, and in
some cases, death.

The GARP research estimates that approximately
190,000 neonatal deaths in India ,each year is due to
sepsis – a bacterial infection that overwhelms the
bloodstream and over 30 % are attributable to
antibiotic resistance.
Antibiotic resistant hospital infections can be
especially deadly because:-
 Antibiotics are used intensely in hospitals
compared with the community.
 Frequent use drives the development of highly
resistant bacteria.

Tertiary care hospital in Pune, India (2016)
reported
Overall Prevalence Of Hospital Acquired Infection (HAI) - 3.76 %
Surgical ICU - 25%
 Medical ICU - 20%
 Burns ward - 20%
 Paediatric ward - 12.17%
PREVALENCE OF HOSPITAL ACQUIRED
INFECTION (HAI)

21%
23%
16%
15%
8%
17%
Incidence of Hospital Acquired Infection
(AIIMS New Delhi)
P. aeruginosa
S. aureus
Klebsiella
Acinetobacter
baumannii
Escherichia coli
Other pathogens

What is HIA - (Hospital acquired infection)
An infection occurring in a patient in a hospital or other
health care facility, in whom the infection was not present or
incubating at the time of admission.
This includes infections acquired in the hospital but
appearing after discharge, and also occupational infections
among staff of the facility .
Hospital acquired infection is also called as Nosocomial
infection .

Potential Sources For HAI
 Hot/Cold Water
Systems
 CoolingTowers
 Evaporative
condensers
 Respiratory Equipment
 Spa pools, Natural
pools,Thermal springs
 Fountains/Sprinklers
 Humidifiers for food
display cabinets
 Water cooling machine
tools
 Vehicles washes
 Ultrasonic misting
machine

Patients at risk of Noso comial infections
 Age more than 70 years
 Major trauma
 Acute renal failure
 Coma
 Prior antibiotics
 Mechanical ventilation
 Drugs affecting the immune system like steroids,
chemotherapy
 Indwelling catheters
 Prolonged ICU stay (>3 days).

Quality assurance in nursing
is about ensuring adherence
to quality standards as
mandated by nursing
regulatory bodies.
Quality assurance in nursing
assesses what health care
processes are in place and
what else needs to be
implemented to better the
system.
So What to do - ???..
The Answer is Quality assurance

Definition
 Quality assurance is an on- going, systematic,
comprehensive evaluation of health care services and
the impact of those services on health care services.
Kozier
 Quality assurance is defined as all activities
undertaken to predate and prevent poor quality.
Neetvert

CONCEPT OF QUALITY IN HEALTH CARE IS :
 The extent of resemblance between the
purpose of healthcare and the truly granted
care.
Donabedian 1986
 To ensure that the product consistently
achieved customer satisfaction.
 A dynamic process through which nurses
assume accountabilityfor quality of care
they provide.

The monitoring of the activities of client care to
determine the degree of excellence attained to the
implementation of the activities”.
(Bull, 1985)
 Defining of nursing practice through well written
nursing standards and the use of those standards as a
basis for evaluation on improvement of client care
(Maker 1998).

OBJECTIVES OF QUALITY ASSURANCE
According to Jonas (2000), the two main
objectives are :
 Ensure the delivery of quality client care.
 Demonstrate the efforts of the healthcare
providers to provide the best possible results.

Contributory objectives :
 Formulate plan of care
 Attend the patients physical and non-
physical needs
 Evaluate achievement of nursing care
 Support delivery of nursing care with
administrative and managerial services

• Lack of resources- infrastructure equipment
• Personal problem
• Improper maintenance
• Absence of well informed populace
• Absence of Accreditation
• Absence of conducting patient satisfaction survey
• Lack of nursing care records
• Miscellaneous factors
• Lack of adequate nurse administrator

MUTUALLY
BENEFICIAL SUPPLIER
FACTUAL
APPROACHTO
DECISION MAKING
CONTINUAL
IMPROVEMENT
SYSTEM
APPROACH TO
MANAGEMENT
PROCESS
APPROACH
INVOLVEMENT
OF PEOPLE
CUSTOMER
FOCUS
LEADERSHIP

 Structure evaluation
 Process evaluation
 Outcome evaluation

Staff
Departments
Equipment
Supplies
Environment
Pathways
Protocols
Physicians
Orders
Nursing Care
Housekeeping
Transport
Six Ds:
Death
Disease
Disability
Discomfort
Dissatisfaction
Destitution
(Cost)
ANATOMY
Process
Care
Process
HEALTH CARE MODEL: DONABEDIAN MODEL
Structure
Outcome

The Donabedian model
is a conceptual model that provides a framework for
examining health services and evaluating quality of health
care.
 According to the model, information about quality of care
can be drawn from three categories:
 Structure : It describes the context in which care is
delivered, including hospital buildings, staff,
financing and equipment.
 Process : denotes the transactions between patients and
providers throughout the delivery of healthcare. the
measurement of process is nearly equivalent to the
measurement of quality of care because process
contains all acts of healthcare .
 Outcomes : refers to the effects of healthcare on the health
status of patients and populations.

Donabedian’s model can also be applied to a large
health system to measure overall quality and align
improvement work across a hospital, group practice or
the large integrated health system to improve quality
and outcomes for a population.

ANA QUALITY ASSURANCE MODEL
Identify
structure,
standard
and criteria
Apply the process,
standards and
criteria
Evaluate
Outcome of
standards
and criteria

The basic components of the ANA Model
are:
 Identify values
 Identify structure, process and
outcome standards and criteria
 Select measurement
 Make interpretation
 Identify course of action
 Choose action
 Take action
 Reevaluate

ISO QUALITY ASSURANCE MODEL
Continual Improvement of the Quality
Management System
Customers
Requirements
Satisfaction
Output
Customers
Management
Responsibility
Resource
Management
Product
Realizations
Measurement
analysis and
improvement
Do Check
Act
Plan
Input Product

JOINT COMMISSION ONACCREDITATION OF HOSPITAL
ORGANIZATIONS (JCAHO) - QUALITYASSURANCE MODEL
Delineatescope
* HospitalInfectionControl
* Incidence
Identifyimportantaspects of HAI * Awareness
* Administrative and clinicalset up
* TrainingRequisites
* Implementation
Identifyindicators * Structure,Process and Outcome criteria
Establishstandards * Such as <2% incidenceof HAI for all procedures/
for evaluation surgicaloperations/patient admissions
Collect Data
Compare withstandards * Identifyareas of improvement
* Take corrective measures
Attained NotAttained
Enhance standards

PREVENTIVE MEASURES
 Keep all showers, showerheads and taps clean and
free from scale
 Clean and Disinfect cooling towers used in air
conditioning systems regularly – every 3 months
 Clean and disinfect heat exchangers( calorifiers)
regularly- once a year
 Disinfect the hot water system with high level
chlorine for 2-4 hours after work on heat exchangers

Contd...
 Clean and disinfect all water filters regularly- every
one to three months.
 Inspect storage tanks, cooling towers and visible
pipe work monthly. Ensure all coverings are intact
and firmly in place.
 Ensure that system modifications or new
installations do not create pipe work with
intermittent or no water flow.

APPROACHES FOR A QUALITY
ASSURANCE PROGRAMME
Major categories of approaches
1.General
2.Specific
General
approaches
Credentialing
Licensure
AccreditationCharter
Academic
Degree

A. GENERAL APPROACH
• It involves large governing of official body’s
evaluation of a person’s or agency’s ability to meet
established criteria or standards at a given time.
1. Credentialing
• Formal recognition of professional or technical
competence and attainment of minimum
standards by a person or agency.
Credentialing process has four functional
components
a) Produce a quality product
b) Confer a unique identity
c) Protect provider and public
d) Control the profession.

2) Licensure
• Individual licensure is a contract between the
profession and the state, in which the
profession is granted control over entry into and
exists from the profession over quality of
professional practice.
• The licensing process requires that regulations be
written to define the scopes and limits of the
professional’s practice.
• Licensure of nurses has been mandated
throughout the world by laws and regulations..

3) Accreditation
• International Organization for Standardization (ISO)
The International Organization for Standardization
(ISO) is an international standard-setting body
composed of representatives from various national
standards organizations. Founded on 23 February
1947, the organization promotes worldwide
proprietary, industrial and commercial standards.
• Joint Commission International (JCI)
Was founded in the late 1990s to survey hospitals
outside of the United States. JCI, which is also not-for-
profit, currently accredits facilities in Asia, Europe, the
Middle East, and South America.

• National Accreditation Board for Hospitals &
Healthcare Providers (NABH)
National Accreditation
Board for Hospitals &
Healthcare Providers is a
constituent board of
Quality Council of India
Certification, set up to
establish and operate
accreditation programme
for healthcare
organizations. NABH was
established in year 2006.

• National Assessment and Accreditation
(NAAC)
The National Assessment and Accreditation Council
(NAAC) is an organization that assesses and
accredits higher education Institutions (HEIs) in India.
It is an autonomous body funded by University Grants
Commission of Government of India headquartered in
Bangalore
• Accreditation Canada
An accreditation body, works with patients, policy
makers and the public to improve the quality of health
and social services for all.

4. CERTIFICATION
Certification is usually a voluntary process with in
the profession.
A person’s educational achievements, experience
and performance on examination are used to
determine the person’s qualifications for functioning
in an identified specialty area.
Specific approaches
1) Peer review
Peer review is divided in to two types.
The recipients of health services by means of
auditing the quality of services rendered.
The health professional evaluating the quality of
individual performance.

2) Standard as a device for quality assurance
Standard is a pre-determined baseline condition or level
of excellence that comprises a model to be followed and
practiced. The ANA standard for practice include:
Standard 1: The collection of data about health status
of the patient is systematic and continuous.
The data are accessible, communicative, and recorded.
Standard 2: Nursing diagnosis are derived from
health status data.

Standard 3: The plan of nursing care includes goals
derived from the nursing diagnoses.
Standard 4: The plan of nursing care includes
priorities and the prescribed nursing approaches or
measures to achieve the goals derived from the nursing
diagnoses.
Standard 5: Nursing actions provide for patient
participation in health promotion, maintenance, and
restoration.

Standard 6: Nursing actions assist the patient to
maximize his health capabilities.
Standard 7: The patient’s progress or lack of progress
towards goal achievement is determined by the patient
and the nurse.
Standard 8: The patient’s progress or lack of progress
towards goal achievement directs re-assessment, re-
ordering of priorities, new goal setting, and a revision of
the plan of nursing care.

3) Audit as a tool for quality assurance
Nursing audit may be defined as a detailed review and
evaluation of selected clinical records in order to evaluate
the quality of nursing care and performance by comparing it
with accepted standards.

Prevention of Noso comial Infection
Sterilization
Isolation
Hand washing
Gloves
Surface sanitation
Antimicrobial surfaces

CONCLUSION
*Staff Education *Surveillance *Interrupting Transmission

Quality assurance -Models & approaches

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Quality assurance -Models & approaches